Opioid Conversion Ratios Guide to Palliative Care …

1 Opioid Conversion Ratios Guide to Palliative care Practice 2016 3/5/2016 2016. The EMR PCC grants permission to reproduce parts of this publication for clinical and educational use only, provided that the Eastern Metropolitan Region Palliative care Consortium is acknowledged. Requests to reproduce this document, for purposes other than those stated above, should be addressed to: Consortium Manager Eastern Metropolitan Region Palliative care Consortium PO Box 2110 Rangeview 3132 Victoria Australia Eastern Metropolitan Region Palliative care Consortium (Victoria) Opioid Conversion Ratios - Guide to Palliative care Practice 2016 2016.

2 It is highly recommended this Guide is printed in colour, to aid ease of use. The access point for the current electronic version of the Guide is Eastern Metropolitan Region Palliative care Consortium or Centre for Palliative care Printed versions can only be considered up-to-date for a period of one month from the printing date after which, the latest version should be downloaded ACKNOWLEDGEMENTS EMRPCC Opioid Conversion Guide Review 2016 Project officer: Ms S Scholes, BPharm Grad Cert Heath ( Palliative care ) MSHP Victorian Palliative Medicine Specialists: Dr P Poon; Dr M Benson; Dr M Franco and Dr L William who provided fresh perspectives on the 2016 document.

3 EMRPCC Clinical Group (2016): Eastern Health: Dr L William ( Palliative Medicine Specialist), Ms J Wilkinson & Ms D Bach (Clinical Nurse Consultants) Eastern Palliative care Association Inc: Mr D Halliwell (Clinical Nurse Consultant) St Vincent s Health Melbourne & Eastern Palliative care Association Inc: Dr P Sherwen ( Palliative Medicine Specialist) St Vincent s Health Melbourne: Mr T Whelan (Nurse Practitioner) Eastern Metropolitan Region Palliative care Consortium: Ms C Clifton (Consortium Manager) Special Acknowledgments: Ms A Padrissa & Ms K McGrath, Eastern Health (Wantirna Health) Palliative care Pharmacists Ms S Chung, St Vincent s Hospital (Melbourne), Medicines Information Pharmacist (Covering) Acknowledgement for previous documents: Acknowledgment is also extended to the original 2008 EMRPCC clinical group and all contributors to the initial EMRPCC Opioid Conversion Ratios Guide to Practice (October 2008) and the members of the EMRPCC clinical groups who revised the document EMRPCC Opioid Conversion Ratios - Guide to Practice (December 2010 and again in July 2013).

4 The EMRPCC welcomes feedback. Please send comments to: Consortia Manager, Eastern Metropolitan Region Palliative care Consortium PO Box 2110 Rangeview Victoria Australia 3132 or email Eastern Metropolitan Region Palliative care Consortium (Victoria) Opioid Conversion Ratios - Guide to Palliative care Practice 2016 2016. Contents ACKNOWLEDGEMENTS .. 2 DISCLAIMER .. 4 GENERAL NOTES .. 4 ORAL MORPHINE TO OTHER ORAL OPIOIDS .. 5 ORAL OPIOIDS TO SUBCUTANEOUS OPIOIDS same drug to same 5 SUBCUTANEOUS MORPHINE TO OTHER SUBCUTANEOUS OPIOIDS .. 6 MORPHINE TO TRANSDERMAL FENTANYL .. 6 Conversion Guide FOR Opioid TO TRANSDERMAL FENTANYL .. 7 SUBCUTANEOUS FENTANYL TO TRANSDERMAL FENTANYL - same drug to same drug.

5 7 TRANSMUCOSAL FENTANYL .. 7 TRANSDERMAL BUPRENORPHINE TO ORAL MORPHINE .. 8 METHADONE .. 8 ORAL METHADONE TO SUBCUTANEOUS METHADONE same drug to same drug .. 9 REFERENCES 2016 .. 10 Summary Chart .. 11 Eastern Metropolitan Region Palliative care Consortium (Victoria) Opioid Conversion Ratios - Guide to Palliative care Practice 2016 2016. Page 4 of 12 DISCLAIMER GENERAL NOTES The conversions are applicable in pain for Palliative care patients rather than patients with chronic pain It is recommended that opioids be converted to the equianalgesic oral morphine as the first step, except when converting from the same drug to the same drug ( oral to subcutaneous)

6 When converting, calculate the equianalgesic starting dose of the new Opioid using the guidelines Apply a dose reduction of 25% to 50% to the equianalgesic starting dose to allow for cross-tolerance A dose reduction closer to 50% is appropriate if the patient is elderly or medically frail Also consider o dose and duration of previous Opioid treatment o current pain severity o patient s ethnicity, for example, oxycodone may be metabolised differently by Caucasian, Asian and North African groups due to genetic polymorphism o renal function, for example, use caution in mild to moderate renal impairment with hydromorphone, morphine and oxycodone. Consensus guidelines suggest fentanyl is the Opioid of choice in severe renal impairment o hepatic function, for example, decrease the dose and frequency of administration of morphine in hepatic failure, and avoid oxycodone in severe cirrhosis.

7 Fentanyl is preferred in moderate to severe liver failure or cirrhosis o occurrence of adverse effects o direction of switch of Opioid , methadone to morphine Prescribe prn breakthrough Opioid during the titration process of 1/10th to 1/6th of the total daily Opioid dose Frequently monitor for patient response and individual dose titration (References 1,2,3) The information in this document is to be used as a Guide to practice only. It is the responsibility of the user to ensure the information is used correctly. This Guide reflects current Palliative care practice in the Eastern Metropolitan Region of Melbourne and published evidence at the time of the review. The current electronic version of the document is available at and should always be referred to.

8 All medication doses derived from this Guide to practice, should be checked and prescribed by a medical doctor or nurse practitioner with appropriate experience in Opioid prescribing. Opioids may be given via different routes as part of clinical practice, to reflect clinical needs, however not all routes ( intrathecal) have been covered in this Guide . Medication doses should be modified in response to the patient/client s clinical situation and status, including previous exposure to opioids and concurrent medications. All patients should be monitored closely until stable when commencing, adjusting dosage and/or switching Opioid medications. Adhere to all legislation and professional requirements including organisational policies and procedures regarding Opioid medications and their administration.

9 Eastern Metropolitan Region Palliative care Consortium (Victoria) Opioid Conversion Ratios - Guide to Palliative care Practice 2016 2016. Page 5 of 12 ORAL MORPHINE TO OTHER ORAL OPIOIDS Oral To Oral Conversion Ratio Example Comments Reference Morphine to Codeine 1:10 Oral Morphine 6mg = Oral Codeine 60mg Avoid Conversion and treat as Opioid na ve Codeine has a limited role in managing moderate-severe pain in Palliative care 3,4,5,6 Morphine to Hydromorphone 5:1 Oral Morphine 5mg = Oral Hydromorphone1mg 3,4,5 Morphine to Methadone Palliative care Specialist input required See Methadone on pages 8-9 for more information Morphine to Oxycodone :1 Oral Morphine 15mg = Oral Oxycodone 10 mg The oxycodone component of Targin should be considered in conversions.

10 If doses greater than Targin 80/40 mg per day are required, single entity modified release oxycodone should be used. Note the beneficial effect of naloxone on bowel function may be impaired 3,4,5,6,7 Morphine to Tapentadol 1:3 Oral Morphine 100mg = Oral Tapentadol 300mg 3,8,9 Morphine to Tramadol 1:5 to 1:10 Oral Morphine 10mg = Oral Tramadol 50 to100mg Tramadol has a limited role in managing moderate to severe pain in Palliative care 3,4,6 ORAL OPIOIDS TO SUBCUTANEOUS OPIOIDS same drug to same drug Oral Subcutaneous Conversion Ratio Example Comments Reference Morphine Morphine 2:1 to 3:1 Oral Morphine 30mg = Subcutaneous Morphine 10 to 15mg 3,4,6 Oxycodone Oxycodone :1 to 2:1 Oral Oxycodone 30mg = Subcutaneous Oxycodone 15 to 20mg 3,4,6 Hydromorphone Hydromorphone 2:1 to 3.